COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

ENVIRONMENTAL HEALTH D 'PARTMENT SAN JOAQUIN COUNTY Program Coordinators D*4'Donna K. Heran., R.E.H.S. Kasey L. Foley, R.E.H.S. Director 1868 E. Hazelton Ave., Stockton, California 95205 Robert McClellon, R.E.H.S. Telephone: (209) 468-3420 Fax. (209) 468-3433 Jeff Carruesco, R.E.H.S. Web: www.sjgov.org/ehd Linda Turkatte, R.E.H.S. Rodney Estrada, R.E.H.S. SITE HEALTH & SAFETY PLAN Adrienne Ellsaesser, R.E.H.S. PART I GENERAL SITE INFORMATION ^ / I. Site Name: kwdo Address:ff a' Dack— Contact Person: V� f% e i Phone #: % Z113 ;32/ IF X 27— , , Proposed Date of investigation/inspection: 2. Description and brief narrative of inspection activity: ❑ New UST installation ❑ UAR Investigation ❑ Tank Closure in Place ❑ Tank/Pipe Repair ❑ Tank/Pipe Removal ❑ Re -excavation ❑ Sampling ❑ Boring/Monitoring Well installation XHazardous Waste inspection ❑ Tiered Permitting inspection ❑ Hazardous Materials Business Plan 3. Specific Site Information: Tank No.: Tank Capacity: Tank Content: Tank Age:_ Other: 4. Type of Operation: Red /I alt7t./)eiz�,02 5. Release History: Evidence of leaks/soil contamination: ❑ YES ❑ NO Documented Groundwater contamination: ❑ YES ❑ NO Background and description of any previous investigation or incidence: 6. Potential Health & Safety Physical Concerns: (check all that apply & describe) ❑ Heat or Cold Stress: °F (high ambient temp.) Noise Sources: ❑ Oxygen Deficiency: excavation (falls, trips, slipping, cave-ins): Handling and Transfer of a Hazardous Substance (fire, explosions, etc.): ❑ Confined space entry (explosions): 35jleavy equipment (physry & trauma resulting from moving equipment): 711U ❑ Other (specify): 7. Anticipated Biological Hazards: ❑ Snakes Ansects ❑ Rodents ❑ Poisonous Plants ❑ Other/Unknown (specify): 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.): EH 23081 (1/2/2013) PART II EVALUATION OF POTENTIAL HAZARDS Chemicals Hazards //�� Carcinogens: 0/�5��IG1%/�T�� ❑ Corrosives: ❑ Dusts: ❑ Explosives: $Flammables: 01144/1 r(7/7 ❑ Inorganic Gases: ❑ Metals: Oxidizers: BiSG/— ❑ PCBs: 1WOther; Lij(1C1Q['%I/O�/C�L CfO�'D/1Le� PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT I. Monitoring Equipment (Note: Monitoring instruments must be used for all operations unless appropriate rationale or restrictions are provided): ❑ Combustible Gas/Oxygen Meter ❑ Detector Tubes (specify): ❑ Photo ionization Detector ❑ Organic Vapor Analyzer ❑ Other (specify): None (see below) If monitoring instruments are not used, rationale or activity/area restrictions: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C ❑ D ❑ Hard Hat afety Glasses/Goggles Steel toed/shank shoes or boots ❑ Flame retardant coveralls ❑ Hearing protection ❑ Tyvek ❑ Respirator: ❑ APR ❑ SCBA A/P Cartridge: Safety vest ❑ Two-way communication ❑ Other (specify): PART IV PLAN APPROVAL Plan Prepare Date: % Plan Approved by: -'# "_� ny_..e� fi r7-r� Date: